CPT 99307 Subsequent Nursing Facility Benchmarks

CPT code 99307 represents subsequent nursing facility care for the evaluation and management of patients, focusing on those who are stable, recovering, or improving. This code is widely used in skilled nursing facilities across the United States and is recognized by major payers including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. The service typically involves a problem focused interval history, examination, and straightforward medical decision making, with about 10 minutes spent per patient encounter.

This publication provides a comprehensive overview of CPT code 99307, including payer coverage, clinical context, and policy updates relevant to facility-based care. Readers will gain insights into benchmarks for utilization, reimbursement trends, and the regulatory landscape affecting subsequent nursing facility evaluation and management services. The analysis also highlights the importance of accurate coding and documentation for compliance and quality reporting in skilled nursing settings. Key modifiers and associated taxonomies are discussed to clarify billing practices and ensure proper claim submission. The information is designed to support healthcare professionals, administrators, and policy analysts in understanding the national significance of CPT code 99307 within the broader context of post-acute care.

CPT Code Overview

CPT code 99307 is used for subsequent nursing facility care, specifically for the evaluation and management of a patient. This service requires at least two of three key components: a problem focused interval history, a problem focused examination, and straightforward medical decision making. Counseling and coordination of care with other physicians, qualified health care professionals, or agencies are provided as needed, consistent with the nature of the patient's problems and their needs. Typically, the patient is stable, recovering, or improving, and the service involves approximately 10 minutes spent at the bedside and on the patient's facility floor or unit. The typical site of service for CPT code 99307 is a skilled nursing facility, which is a facility-based setting (Place of Service 31).

Clinical Context

A typical patient scenario involves an elderly individual residing in a skilled nursing facility who is stable, recovering, or improving. The patient may have conditions such as difficulty walking, bed confinement, a history of falls, amnesia, or be receiving palliative care. During a subsequent nursing facility visit, the physician or qualified healthcare professional performs a problem-focused interval history and examination, and makes straightforward medical decisions. The visit typically lasts about 10 minutes and may include counseling or coordination of care with other providers or agencies, tailored to the patient's needs.

Coding Specifications

Modifiers:
- 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. Used when an E/M service is distinct from other procedures performed on the same day.
- 59: Distinct Procedural Service. Used to indicate that a procedure or service is separate and distinct from other services provided on the same day.
Provider Taxonomies:

Taxonomy Code	Specialty Name

For CPT code 99307, national mean rates show that commercial payers, represented by BUCA, average $51.61, while Medicare's mean rate is $43.32. This indicates that commercial reimbursement is typically higher than Medicare for this service.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Medicare exhibits the tightest range ($3.00), suggesting minimal variation in rates. In contrast, Cigna has the widest dispersion ($33.00), followed by UnitedHealth Group ($32.00) and Blue Cross Blue Shield ($23.13), reflecting greater variability in commercial rates.

The table and chart below present a detailed breakdown of national benchmarks for each payer.

Related Diagnoses

Z51.5: Encounter for palliative care
- Relevant for patients receiving palliative care services during their stay in the nursing facility.
Z74.01: Bed confinement status
- Indicates patients who are confined to bed, often requiring ongoing evaluation and management.
Z91.81: History of falling
- Important for patients with a history of falls, necessitating regular assessment and preventive care.
R26.2: Difficulty in walking, not elsewhere classified
- Pertinent for patients with mobility issues, which are common in nursing facility populations.
R41.3: Other amnesia
- Applies to patients experiencing memory loss or cognitive impairment, requiring monitoring and management.

Related CPT Codes

99308: Expanded problem-focused history, expanded problem-focused examination, low complexity medical decision making, typical time = 15 minutes.

99308 is related to 99307 as both are used for subsequent nursing facility care. 99308 represents a higher level of service, with more comprehensive history and examination, and more complex medical decision making. In clinical workflow, 99307 is used for stable or improving patients requiring straightforward decision making, while 99308 is used when the patient's condition or complexity requires more time and evaluation. These codes are alternatives depending on the clinical scenario and documentation.

The table and chart below present a detailed breakdown of national benchmarks for each payer.

OpenPayer

Summary & Overview

CPT 99307: Subsequent Nursing Facility Evaluation and Management